Crystal Huang: The Case

HPI:

Crystal Huang is a 14-year-old female who is brought to the pediatric clinic for complaint of headache. This visit was scheduled in follow-up by the ER social worker as a new patient in your clinic after she was taken to the ER several times in the previous weeks for the headache and vomiting. Records from the last ER visit show:

vitals of T 98.1 HR 74 BP 145/90 RR 16, weight 170 kg

a recorded physician history of “Pt with bipolar d/o and behavior problems here from inpatient facility who is well known to us for prior visits for headache. Currently c/o severe headache: frontal, nausea/vomiting, has had before, some relief with over-the-counter medications (OTCs), denies new neurologic deficits.”

a checkmark in each “normal” box for the HEENT, lung, cardiovascular, and neurologic exams.

nurse assessment of pain that was 10/10 and then subsided to 5/10, when given IV ketorolac and IV ondansetron.

and a discharge instruction sheet with the diagnosis of migraine headache with direction to follow up with a primary care physician.

In taking your own history, you find that Crystal has lived for the last six months in a secure living facility for minors who have psychiatric and behavioral problems refractory to outpatient treatment. She was brought to the appointment by a worker at the facility.

Crystal is cooperative during the visit; saying, “My head is hurting so bad!” She describes the headache as throbbing and severe, and localizes the pain to the frontal area. This headache first began to be noticeable a month ago, but has gotten progressively worse since then. Sometimes the pain is bad enough to wake her from sleep, and she has vomited a few times in the mornings due to the pain. The pain gets worse when she coughs or “goes number two,” and does not get better with food, rest, or over-the-counter medications. She has also had some spells of dizziness at times, when the headache is really bad. She denies any numbness or weakness, but says sometimes her vision is blurry.

Crystal was in foster care for many years, prior to removal to her current facility, and no records are accessible that give her family’s medical history. Her personal medical record, according to the facility’s records given to you by the worker, show that she carries diagnoses of borderline personality d/o, bipolar d/o, and conduct d/o. She also has moderate cognitive impairment which has been attributed to fetal alcohol syndrome.

Her medications are: olanzapine, TriNessa, and valproic acid, and her medication sheet from her facility indicates she has been taking these as prescribed, in addition to acetaminophen or ibuprofen every day for headache.

Physical Exam:

T 98.9 HR 81 BP 155/95 RR 14, weight 167 kg

Gen: looks as if she is in pain, cooperative, somewhat unkempt.

HEENT: Pupils are reactive and equal bilaterally, and sclera are clear. Throat is clear with normal gag reflex. TM’s are clear bilaterally, and neck is supple. There is no tenderness over the scalp or temples, and she is able to bite on a tongue blade without pain. She has no pain with palpation of the frontal sinuses. There is no cervical lymphadenopathy. Retinal exam and appearance of eyes when asked to look to each side is shown below. The worker with her says, “Yeah, her eyes have been doing that; that is why we kept taking her back to the ER.” See Figures 1 and 2

The remainder of her examination, including examination of other cranial nerves, gait, deep tendon reflexes, proprioception, and sensation/strength over the face and body, is normal.

Workup: You send Crystal to the local ER and call ahead to discuss her case with the ER doctor on shift, and request a CT head as part of her care in the ER.

The ER physician calls a neurosurgical consultant; who sees the patient, recommends stopping all existing medications, starting acetazolamide orally, then following the patient up in clinic in one week. The neurosurgeon also recommends ophthalmologic consultation for visual field evaluation. See Figure 3

You see her again in clinic to follow-up from the ER visit a few days later. She says her headache improved after the lumbar puncture but is slowly getting worse again. Her retinal exam is unchanged, as is her eye exam, and she is scheduled to see the ophthalmologist the following day. She has been taking the acetazolamide, but the worker accompanying her carries a note from the psychiatrist in her inpatient facility, who asks if she can restart her other medications due to increasing mood lability, trouble picking physical fights with the other patients in her facility, as well as threats of self-harm. The note explains that the consensus from her medical team is that if psychiatric medications cannot be restarted at this time, Crystal will have to be transferred from the treatment facility to a detention facility with less access to psychiatric disease management. In addition, Crystal has now started menstruating since being taken off the TriNessa a few days prior and wants to see if she can get “the shot” to suppress menstruation.